For each question
please mark the answer which is closest to your personal case (open the box of the different answers with the arrow pointed towards the bottom). This arrow is to be found at the far right hand of each box. Make your choice by choosing the most appropriate answer or enter the corresponding checkbox zone.

General information

Select the date of the day
I fill the questionary for myself / I am a health prationar
Name - Initials of the name or pseudonyme
Christian name
Would you like to be contacted by us or by e-mail ?

E-mail adress
(e-mail adress is desirable but facultative - if you want to be contacted, e-mail us or if you are an health practionar you must fill out this item)

Sex Age Hight (feet) Hight (inches)

Hight (meter) Weight (lbs) Weight (kg)

I live in
in

I live in / at

How did you come accross this questionary ?

Q u e s t i o n s

1) Type of intolerance ?(several answers can be checked)

I think I am lactose intolerant
I have been diagnosed to have a lactose intolerance
I think I am gluten intolerant / celiac disease
I have been diagnosed to have a gluten intolerance / celiac disease
I think I am milk intolerant
I have been diagnosed to have a milk intolerance
I think I have Crohn's disease or colitis disease
I have been diagnosed to have Crohn's disease or colitis disease
I think I have an irritable bowel syndrome
I have been diagnosed to have an irritable bowel syndrome
I don't know if I have a lactose or a milk intolerance
I don't know if I have a lactose or other intolerance

2) Type of symptoms ? (if they are present)(several answers can be checked)
I have diarrhea
I have pain - cramps
I have bloating
I have gas
I have nausea

26) Do you tolerate the following cheese?
&nbsp&nbsp&nbsp (choose between Yes / No or ??? (I don't know))

Yes

No

???

- Cottage cheese

- Cheddar

- Swiss

- Ricotta

- Lactose free cheese

- Tofu

- Others (Please precise)

27) Do you use the following fat products : ?

Yes (1-3X/week)

Yes (+ than 3X/week)

No

- Margarine

- Minarine - Nostrossls

- Butter

- Light butter

- Others (Please precise)

28) Do you use dressings or sauces with your salades : ?

Yes (1-3X/week)

Yes (+ than 3X/week)

No

- Mayonnaise, sauce or industrial vinaigrette

- Mayonnaise, sauce or vinaigrette home
&nbsp&nbsp&nbsp&nbsp made

- Sauce dressing or light industrial

- Sauce dressing or light home
&nbsp&nbsp&nbsp&nbsp made

- Lactose free mix home made

- Others (Please precise)

29) Do you eat the following : ?

Yes (1-3X/week)

Yes (+ than 3X/week)

No

- Chips

- Peanuts

- Aperitif biscuits

- Chocolate

- Snacks

- Chocolate sweets

- Chocolate products

- Sweets

- Others (Please precise)

IMPORTANT : reconnect yourself and : send the questionary
EXCLUSIVELY
by pushing on the button : "Send the questionary by clicking on this button". You may send us a comment or ask us one or several questions by filling in the following zone. You may also bring us some more informations about one or several question(s).
In this case please mention the number(s) of the question(s).

asbl MEDISPORT - Questionnaire on lactose intolerance - Objectives : try to know the eating habits, difficulties, symptoms & diet of the lactose intolerant people aged of 18 year old & over
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